I am a Registered Nurse with over 15 years of diverse experience in both clinical and corporate healthcare settings. My expertise spans nurse management, adult and pediatric emergency/trauma, home care, geriatrics, urgent care, nurse instruction, basic life support training, and vaccine coordination. I specialize in providing care and support to at-risk populations impacted by social determinants of health, including pregnant women, the elderly, children, individuals with disabilities, and those facing financial barriers to accessing healthcare.

 

In the corporate healthcare sector, I bring extensive experience in Managed Care, focusing on Utilization Management (UM) and Population Health. I have in-depth knowledge of regulatory standards, including CMS guidelines, Federal Regulations, NCQA requirements, and State Codes applicable to Medicare, Medicaid (MA), Marketplace, and CHIP programs. My previous corporate roles include UM Clinical Care Reviewer, Medical Loss Unit Specialist, and Prior Authorization Analyst. In the analyst role, I managed a database of over 25,000 CPT codes, ensuring accurate reporting of medical procedures and services to Managed Care Organizations. This involved overseeing quarterly updates, including revisions, deletions, and the addition of new codes, which were integrated into payment systems and online search tools containing prior authorization rules.

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I served as the Clinical Lead for New Markets at AmeriHealth Caritas, where my work impacted over 500 frontline clinical review and intake staff. I was responsible for developing and implementing corporate policies, procedures, and workflows for the Utilization Management (UM) Department. My role included significant contributions at the contract and RFP levels, such as negotiating strategies and addressing state-specific nuances in alignment with federal and NCQA regulations for multi-million-dollar Medicare, Medicaid, and Marketplace exchange programs.

I collaborated with cross-functional teams to develop state-specific readiness review tools based on feedback from state agencies, ensuring compliance and operational readiness. These readiness reviews, which required 50% travel, involved face-to-face presentations to demonstrate our organization's ability to enroll members, maintain continuity of care, and meet the diverse needs of the Medicare-Medicaid population.

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Additionally, I acted as a UM internal consultant to proposal writers and the capture analyst team, liaising between frontline staff, Directors, and Executive leadership to ensure alignment and effective communication."

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AmeriHealth Caritas has over 9,000 employees and is ranked as one of the top MCO companies in the U.S.